Clinical data such as vital sign data and laboratory test results need to be reviewed for many medications, prior to administration, to ensure the continued safety and efficacy of each dose. Some of this data needs to be collected at the time of medication administration, while other data is collected and reported at different times (before or after giving the medication). The collection, recording and reporting of this data can be performed by using different methods. However, this information is frequently documented in other ancillary systems or on paper which adds to clinician workload through the need to spend time locating data.
Laboratory test results and vital sign data needs to also be reported and recorded at the appropriate time (e.g. most recent INR (International normalized ratio), aPTT (activated partial thromboplastin time) drawn 4-6 hours prior to a heparin rate change, gentamicin trough level drawn prior to a dose being administered) so that a clinician can make a correct evaluation of patient status. However, it is not always apparent to the clinician that the data that was reported was collected at an incorrect time. Incorrectly reported data can result in an inappropriate clinical decision and patient harm.
In known systems a user manually enters data that is frequently documented in different systems and locations (electronic and manual). There may also be a duplication of work as vital sign data may be collected by a different clinician from the clinician who administers medications. Further, known systems lack data validation making it difficult to identify when a reported vital sign or laboratory test result may not accurately reflect a clinical condition of a patient. A system according to invention principles addresses these deficiencies and related problems.